Multiple divisions

Medical sociology has for many years been one of the most flourishing of specialist sub-disciplines. To appreciate the scope of the subject, Michael Bury's book is an excellent guide. An extensive and distinguished teaching and research career gives Bury a unique vantage point from which to write this overview of the subject. The book should provide orientation in particular to postgraduates who already have some familiarity with the social sciences.

One of the most important chapters draws on Bury's long-standing involvement in research on illnesses such as arthritis to examine the social consequences of chronic illness and disability. Sociology has played a central role in elucidating the diverse consequences for identity, dignity, quality of life and indeed the daily struggle to carry on faced by many of the six million in British society estimated to have some form of disability. Yet, as Bury argues, the role of sociology as one of the voices of the disabled is now challenged by sections of the disability movement as contributing to their oppression.

In another chapter he illustrates the richness and complexity of public views and beliefs about health and illness. By viewing our own society with the anthropologist's sense of strangeness we see how frustrating to the naive ambitions of health promotion are our refractory ideas about food, sex, stress, fate, chance, and heredity that mediate our response to attempts at cardiovascular and cancer prevention.

In other chapters Bury charts a humane, scholarly and wise path through the complexities of social inequalities in health, relations between patients and their doctors and issues surrounding death and dying. A noticeable omission is any discussion of how we organise services to help the ill. This reflects the curious and almost complete concession by sociology of the territory of advice and analysis of the organisation of health services to the grander claims of economists, operational researchers and the ever-present management consultants.

Periodically surfacing throughout the book are the peculiar tensions and disabling ambivalence often felt by medical sociology in its dealings with various sources of power. Bury's perceptive account of work on the doctor-patient relationship makes it clear that, until recently, there was a difficult dilemma in deciding how to relate to the medical profession. By trying to help doctors understand their many difficulties in dealing with patients, did not medical sociology reinforce the very social control its analyses revealed? According to some analyses, power has in part shifted from the doctor to the manager and the accountant. The book conveys suitably dire warnings against medical sociology pursuing the management/accountant agenda. Worse still would be if it allowed itself to be driven by "the government". In a book that is otherwise sensitive to the pluralism and diverse social worlds envisaged by post-modernism, it is surprising to see "the government" reified in this way. The NHS has a research and development programme which is remarkable for its "bottom-up" efforts to involve various constituencies in identifying and prioritising key research questions regarding health care.

Most striking is the ambivalence of the discipline to that most powerful of forces, biology. Bury urges us not to be daunted by biology, in the sense of the organised scientific discipline from which we have much to gain by collaboration. More problematic is biology as a summary term for the physical, uncontrollable insistence of bodies to change, decay and die. The social constructionists and cultural relativists, with whom Bury jousts, struggle with any "reductionist" and "positivist" concession of the independent effects of the body.

Sociological analysis of health and illness sometimes appears to be conducted by two mutually exclusive and unsympathetic camps. On one side are those who view health and illness as revealing sources of insight into modern culture. On the other are those who use increasingly technical methods in a problem-solving manner to evaluate health care. Adjacent disciplines such as economics, statistics and epidemiology seem better at living with their internal variations in function and at retaining overall cohesion. This book in part seeks to overcome growing gulfs in medical sociology; in part seeks to spirit them away by wishful thinking. It is not clear whether a creative tension between camps will deteriorate into mutual incomprehension.

Ray Fitzpatrick is professor of public health and primary care, University of Oxford.